Vehicle Damage Claim Form

You may be able to claim compensation if your vehicle has sustained damages in an Arterial or Distributor road.

Claim Form

Name *

Surname *

Address *

Contact Number *

Date of Incident *

Month

Day

Year

Place of Incident *

Insurance Company *

Supporting documents

Driving License *

Files must be less than 2 MB.
Allowed file types: jpg jpeg pdf.

Receipt *

Files must be less than 2 MB.
Allowed file types: jpg jpeg pdf.

Police Report *

Files must be less than 2 MB.
Allowed file types: jpg jpeg pdf.

Documentary Evidence *

Files must be less than 2 MB.
Allowed file types: jpg jpeg pdf.

Description of Event *

Is First Claim *

I hearby declare that this is my first claim of this incident

No Other Claims *

I confirm that there are no other claims with any insurance company

* Roads not listed do not fall within IM remit

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